BCBS of Kansas Medical Policy Update

Title:   Monitored Anesthesia Care

POLICY Current Effective Date:  October 1, 2016

A. Use of monitored anesthesia care may be considered medically necessary for gastrointestinal endoscopy, bronchoscopy, interventional pain procedures, CT scans, MRIs, cardiac catheterization and PTCAs when there is documentation by the proceduralist and anesthesiologist that specific risk factors or significant medical conditions are present. Those risk factors or significant medical conditions include any of the following:

1. Increased risk for complications due to severe comorbidity (ASA P3* or greater)
2. Morbid obesity (BMI [body mass index] >40)
3. Documented sleep apnea
4. Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment)
5. Spasticity or movement disorder complicating procedure
6. History or anticipated intolerance to standard sedatives, such as:
   1. Opioid dependent
   2. Benzodiazepine dependent
7. Patients with active medical problems related to drug or alcohol abuse
8. Patients younger than 13 years or 70 years or older
9. Patients who are pregnant
10. Patients with increased risk for airway obstruction due to anatomic variation such as:
    1. History of stridor
    2. Dysmorphic facial features
    3. Oral abnormalities (eg, macroglossia)
    4. Neck abnormalities (eg, neck mass)
    5. Jaw abnormalities (eg, micrognathia)
11. Acutely agitated, uncooperative patients
12. Prolonged or therapeutic gastrointestinal endoscopic procedures requiring deep sedation (See Policy Guidelines)

*American Society of Anesthesiologists (ASA) physical status classification system for assessing a patient before surgery:

P1 – A normal, healthy patient

P2 – A patient with mild systemic disease

P3 – A patient with severe systemic disease

P4 – A patient with severe systemic disease that is a constant threat to life

P5 – A moribund patient who is not expected to survive without the operation

P6 – A declared brain-dead patient whose organs are being harvested

B. Use of monitored anesthesia care is considered not medically necessary for gastrointestinal endoscopy, bronchoscopy, interventional pain procedures, CT scans, MRIs, cardiac catheterization and PTCAs in patients at average risk related to use of anesthesia and sedation.

Policy Guidelines

This policy only addresses anesthesia services for diagnostic or therapeutic procedures involving gastrointestinal (GI) endoscopy, bronchoscopy, and interventional pain procedures performed in the outpatient setting.

Monitored anesthesia care can be provided by qualified anesthesia personnel with training and experience in:

• Patient assessment
• Continuous evaluation and monitoring of patient physiological functions
• Diagnosis and treatment (both pharmacologic and nonpharmacologic) of any and all deviations in physiological function.

Procedural/Patient Risks

Examples of prolonged endoscopy procedures that may require deep sedation include endoscopy in patients with adhesions postabdominal surgery, endoscopic retrograde cholangiopancreatography, stent placement in the upper GI tract, and complex therapeutic procedures such as plication of the cardioesophageal junction.

The Mallampati score is considered a predictor of difficult tracheal intubation and is routinely used in preoperative anesthesia evaluation.1 The score is obtained by having the patient extend the neck, open the mouth, and extend the tongue while in a seated position. Patients are scored from classes 1-4 as follows:

Class I: The tonsils, uvula and soft palate are fully visible

Class 2: The hard and soft palate, uvula and upper portion of the tonsils are visible

Class 3: The hard and soft palate and the uvula base are visible

Class 4: Only the hard palate is visible.

Patients with class 3 or 4 Mallampati scores are considered to be at higher risk of intubation difficulty. While the Mallampati score does not determine a need for monitored anesthesia care, it may be considered in determining risk for airway obstruction. Other tests to predict difficult tracheal intubation include the upper lip bite test, the intubation difficulty scale, and the Cormack-Lehane grading system.

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Editor:  Philip Blann (pblann@anesthesiabilling.com).